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Laparoscopy for Endometrial Cancer — 467
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this approach is the fact that, in spite of a low frequency of isolated aortic metastases, it is not always feasible or accurate to
use either frozen section analysis for definition of pelvic lymph
node status or lymphovascular invasion as a possible surrogate
of para-aortic dissemination.[9] Furthermore, systematic aortic
lymphadenectomy has therapeutic value in patients with histologically detected aortic metastases and in those with negative
aortic nodes but histologically undetected micrometastases.[4]
For the other author (J.F.M.), aortic lymphadenectomy to
renal vessels is indicated (1) in the presence of positive pelvic
nodes and (2) in patients with negative pelvic nodes but lymphovascular invasion and outer third myometrial involvement,
as explained later.
Most gynecologic oncologists concur that aortic lymphadenectomy is indicated in all patients with positive pelvic
nodes because of the high frequency of positive aortic nodes in
the presence of pelvic node metastases. Aortic nodal dissection
should be extended to the renal vessels because of the frequent
involvement of the high aortic nodal groups and because of skip
metastases to the high aortic group. In fact, more than 80% of
patients operated on at MayoClinic who had positive aortic nodes
had involvement of the nodes abovetheinferiormesentericartery,
with a high rate of skipping the lower aortic nodes. The high aortic nodes were involved in nine of 11 patients (81.8%) who had
positive aortic nodes. Among these nine patients, skipping of the
ipsilateral nodes below the inferior mesenteric artery (low aortic
nodes) was observed in six (66.7%) patients (unpublished data
from Mayo Clinic).
In the absence of positive pelvic nodes, aortic lymphadenectomy is indicated in patients with lymphovascular invasion and
invasion of the outer third of the myometrium. The presence of
positive aortic nodes in the absence of pelvic node metastases
is uncommon and was observed in only 2% of patients (range,
0% to 3%) (Table 16.5.1).[9–14] However, in patients with negative nodes but lymphovascular invasion, this rate is much higher.
In our experience, three of 181 patients (1.7%) who underwent
systematic pelvic and aortic lymphadenectomy had isolated aortic invasion. In the presence of lymphovascular invasion, positive
aortic nodeswereobserved in asmanyas 9% of patientswith negative pelvic nodes.[9] A common risk factor for all three patients
with negative pelvic but positive aortic nodes was invasion of the
outer third of the myometrium associated with lymphovascular
invasion (unpublished data).
Intraoperative Complications
A review of four studies comparing intraoperative complications
between laparoscopy and laparotomy patients showed reduced
complication rates for laparoscopy patients (Table 16.5.2).
[15–18] In 187 laparoscopy patients, the intraoperative complication rate was 4.2%, whereas it was 11.1% for 164 laparotomy
patients.
Perioperative Data and Morbidity
A review of 17 studies addressing results of perioperative
data (e.g., operating room time, estimated blood loss, number of retrieved lymph nodes, length of hospitalization, and
conversion rates to laparotomy) between 945 laparoscopy and
1039 laparotomy patients with endometrial cancer is shown
Table 16.5.1: Presence of Positive Aortic Lymph Nodes in
Patients with and without Pelvic Node Metastases
Patients with
Negative Pelv ic
Nodes, N +
Study Cancer Stage
Mariani et al.
(2004) [9]
McMeekin et al.
(2001) [10]
Ayhan et al.
(1995) [11]
Fanning et al.
(1996) [12]
Hirahatake et al.
(1997) [13]
Larson and
Johnson (1993)
[14]
Total 1647 + 34 (2) 350 + 42 (12)
∗
We excluded the three patients who had positive para-aortic nodes
but for whom no data were available about the pelvis.
LN, lymph node; NA, not available.
I–IV 90∗+ 2 (2) 51∗+ 2 (4)
I–IV NA 47 + 8 (17)
Clinical I 209 + 6 (3) 36 + 6 (17)
I–III 60 + 0 (0) 5 + 0 (0)
I–IV 200 + 2 (1) 42 + 2 (5)
I–IV 50 + 0 (0) 10 + 0 (0)
Aortic LNs (%)
Patients with
Positive Pelvic
Nodes, N +
Aortic LNs (%)
in Table 16.5.3.[15–17,19–32] Laparoscopy patients experienced
less blood loss (216 vs. 284 mL), reduced hospitalization (3.5 vs.
6.8 days), a similar number of retrieved lymph nodes (16.2 vs.
14.5), and a longer operating time (171 vs. 133 minutes). Major
differences were found in operating times, number of nodes, and
days of hospitalization, depending on the surgeon’s experience;
whether patients had lymphadenectomy and, ifso,whether it was
pelvic or aortic or both; the extent of the lymphadenectomy; and
the usual length of hospitalization for different countries.
Conversion to Laparotomy
Conversion to laparotomy may be necessary because of anesthesia complications or difficulties with ventilation, intolerance
to the Trendelenburg position, intraoperative complications not
amenable to laparoscopic correction, or advanced disease. Conversion rates to laparotomy from all causes range from 0% to
12.4%.[33] However, the rate is lower (0% to 5.3%) when all
conversions due to operative complications are considered.[33]
In 14 studies, the conversion rate due to complications was 2%
(Table 16.5.2).
Various operative reasons (e.g., dense adhesions, uncontrolled bleeding, difficult exposure, inadequate instrumentation,
or equipment failure) may result in a determination by the surgeon to proceed with a laparotomy approach. At Mayo Clinic,
the expertise of the surgeon and the assistant, as well as available instrumentation, plays a major role and may result either
in continuation or in completion of the operation laparoscopically. These factors may also explain the wide range of reported
conversion rates.
468 — Javier F. Magrina, Andrea Mariani, and Paul M. Magtibay
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Table 16.5.2: Comparison of Intraoperative Complications of Laparoscopy versus Laparotomy
in Patients with Endometrial Cancer
Study Patients, no. Complications,% Patients, no. Complications,%
Kuoppala et al. (2004) [15] 40 0 40 0
Magrina et al. (1995) [16] 15 6.6 15 6.6
Occelli et al. (2003) [17] 69 5.6 50 22.4
Tozzi et al. (2005) [18] 63 4.7 59 15.2
Total 187 4.2 164 11.1
Intraoperative Complications
Laparoscopy Laparotomy
There is no doubt that many anesthesiologists look unfavorably on positioning the patient in a deep Trendelenburg tilt
because it resultsin increased ventilation requirements. However,
such patient positioning is necessary for performance of some
gynecologic oncology procedures (e.g., aortic lymphadenectomy) and for execution of a safe and an expeditious pelvic operation. This is particularly true in patients with dilated loops of
small bowel or redundant sigmoid that obstruct the view of, or
access to, the pelvic organs.
Inadvertent injury to the major pelvic veins and vena cava
that results from scissors, cautery, or avulsion of the small tributaries is a common reason for laparotomy. However, this type of
injury canbe repaired laparoscopically as longas adequate visualization can be obtained by proper efferent pressure and effective
suction. One of us (J.F.M.) has effectively repaired injuries to the
vena cava, the left common iliac, and the right external iliac veins
using the following laparoscopic technique. First, a 5-cm precut
4-0 polypropylene suture (Prolene; Ethicon Endo-Surgery, Inc.,
Cincinnati, OH) or similar nonabsorbable suture with a Vicryl
clip (Lapra-Ty; Ethicon Endo-Surgery, Inc.) fastened at the distal
end is introduced. Opposite edges of the injury site are brought
together witha singlepass ofthe needle. The suture isthen pulled
upward. In most instances, pulling the edges together will stop
the bleeding of minor defects. Asecond or third pass of the needle
will occlude most injury sites. After the defect is closed, another
Lapra-Ty is fastened to the suture, flush with the vein wall. When
feasible, such as with bleeding secondary to injury to the external
or common iliac veins, a caudal tourniquet applied with a vessel loop introduced through an additional port will control the
bleeding and allow an unhurried repair.
Adhesions among bowel loops that result in distorted
anatomy can be managed laparoscopically when they are limited to a portion of the abdominal or pelvic cavity and when
proper tissue planes can be identified, dissected, and separated.
The insertion of additional trocars may be necessary to obtain
proper traction and countertraction, or to place the dissecting
scissors in the proper direction. The da Vinci robotic surgical
interface system has articulated instruments that facilitate dissection of problematic adhesions. To prevent thermal intestinal
injury, we use cautery minimally or not at all. The bowel and
colon must always be thoroughly inspected for any injury after
adhesiolysis.
Postoperative Complications
Because the type of annotated postoperative complication varies
among different studies, there is a wide range of reported complication ratesfor patients with endometrial cancer treated either
by laparoscopy or by laparotomy. Some studies address all minor
and major complications, whereas others address only major
complications and still others do not indicate what deviances
from a normal postoperative course should be considered
complications. Reduced postoperative complication rates are
observed among laparoscopy patients compared with laparotomy
patients.
We reviewed 12 reports published between 1995 and 2005
to compare postoperative complications between laparoscopy
and laparotomy patients (Table 16.5.4).[15–17,20,21,23,25–
27,30,34,35] For laparoscopy patients, the range of complications was 0% to 23.8%, whereas it was 0%to 58% for laparotomy
patients. Anincreased rate of complications was observed among
laparotomy-treatedpatients in 10 studies, whereasin the remaining two it was similar (0% and 20%, respectively), with no major
differences observed.
Late complications (≥42 days) are either reduced with
laparoscopy or similar to those of laparotomy patients. In one
study, late complications were observed in only five of 63
laparoscopy patients (7.9%) compared with 21 of 59 laparotomy
patients (35.6%).[35] In another study, late postoperative complications weresimilarbetweenbothgroups(20%vs.22.5%).[15]
Univariate analysis of risk factors for postoperative complications showed that weight of more than 80 kg, Quetelet index
(body mass index; weight [kg]/height [m
2
]) of more than 30,
and age of more than 65 years were highly predictive of complications both for laparoscopy and for laparotomy patients.[35]
Patients who met these parameters experienced 60% of all complications. This group of patients appeared to benefit even more
from a laparoscopic approach. Interestingly,multivariateanalysis
identified the surgical approach as the only significant risk factor
predictive of complications.
Recurrence
Recurrence rates for patients treated laparoscopically are low and
comparable to those of patients treated by laparotomy. A review
of six comparison studies showed the mean rate of recurrence
Laparoscopy for Endometrial Cancer — 469
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Table 16.5.3: Comparison of Perioperative Laparoscopy and Laparotomy Data for Endometrial Cancer
Mean Operating Mean Blood Mean Lymph Mean Hospital Conversion to
Study Patients, no. Time, min Loss, mL Nodes, no. Stay, days Laparotomy,%
Laparoscopy
Kuoppala et al. (2004) [15] 40 145 171 11.1 2.7 0
Magrina et al. (1995) [16] 15 174 272 18.5 3.4 3.4
Occelli et al. (2003) [17] 69 164.5 NA 15.8 4.0 1.2
Boike et al. (1994) [19] 33 217 NA 18.9 2.5 5.3
Eltabbakh (2002) [20] 100 NA 200 13.5 2 1.0
Eltabbakh et al. (2000) [21]
Gemignani et al. (1999) [22] 69† 214 211 7 (0–14) 2.9 3.0
Holub et al. (2002) [23] 177 163.1 211.2 16.8 3.9 3.4
Holub et al. (1998) [24] 11 153 130 NA 4.7 NA
Langebrekke et al. (2002) [25] 27 143 NA 6.8 4.3 3.7
Litta et al. (2003) [26] 29 186 125 14.2 2.5 0
Manolitsas et al. (2002) [27] 161 138 NA NA 4.3 NA
Moore et al. (1999) [28] 80 170 223 20.1 2.5 1.3
Peng et al. (2004) [29] 24 97 163 13.6 6.3 NA
Scribner et al. (1999) [30] 19 237 350 34 3.7 0
Spirtos et al. (1995) [31] 13 NA NA 28 2.4 0
Zapico et al. (2005) [32] 38 165 NA 13.5 5.0 0
Laparotomy
Kuoppala et al. (2004) [15] 40 96 238 7.3 7.6
Magrina et al. (1995) [16] 15 142 502 23.5 6.6
Occelli et al. (2003) [17] 58 122.9 NA 11 9.0
Boike et al. (1994) [19] 37 194.0 NA 18.7 5
Eltabbakh (2002) [20] 40 138 303 5.3 6.5
Eltabbakh et al. (2000) [21]
Gemignani et al. (1999) [22] 251
Holub et al. (2002) [23] 44 114.7 245.7 14.3 7.3
Holub et al. (1998) [24] 26 127 150 NA 7.7
Langebrekke et al. (2002) [25] 24 87 NA 5.6 6.2
Litta et al. (2003) [26] 30 152 153 13.4 6.4
Manolitsas et al. (2002) [27] 230 121 NA NA 8.5
Moore et al. (1999) [28] 45 140 474 11.7 4.1
Peng et al. (2004) [29] 41 134 259 19.6 9.6
Scribner et al. (1999) [30] 17 157 344 30 5.2
Spirtos et al. (1995) [31] 17 NA NA 29.0 6.4
Zapico et al. (2005) [32] 38 130 NA 15.0 7.0
∗
40 195 318 11.3 2.5 2.5
945 171 216 16.2 3.5 1.8
∗
86 NA 250 10.5 5
‡
144 209 6 (0–30) 6.7
1039 133 284 14.5 6.8
∗
Only patients with a body mass index of 28 to 60.
†Only 11 patients with lymphadenectomy.
‡
Only 113 patients with lymphadenectomy.
NA, not available.
470 — Javier F. Magrina, Andrea Mariani, and Paul M. Magtibay
https://t.me/med1917
Table 16.5.4: Comparison of Postoperative Complications
between Laparoscopy and Laparotomy Treatments for
Endometrial Cancer
Postoperative
Complications,%
Study Laparoscopy Laparotomy
Kuoppala et al. (2004) [15] 17.5 32.5
Magrina et al. (1995) [16] 20.0 20.0
Occelli et al. (2003) [17] 1.4 6.9
Eltabbakh (2002) [20] 9.0 18.6
Eltabbakh et al. (2000) [21] 7.5 10.0
Holub et al. (2002) [23] 15.2 20.4
Langebrekke et al. (2002) [25] 3.7 4.1
Litta et al. (2003) [26] 0 0
Manolitsas and McCartney
(2002) [27]
Scribner et al. (1999) [30] 10.5 17.6
Obermair et al. (2005) [34] 21.2 58.0
Tozzi et al. (2005) [35] 23.8 47.4
17.0 43.0
for 654 laparoscopy patients to be 5.4% (range, 0% to 12.6%)
compared with 11.7% (range, 2% to 14.9%) for 477 patients
treated by laparotomy(Table 16.5.5).[15,20,23,25,35,36]Analysis
of patterns ofrecurrence demonstrated similarsites of recurrence
for laparoscopy and laparotomy.[25,36] We observed no vaginal
cuff recurrences,andnovaginalsuturelinerecurrencesinpatients
undergoing vaginal repairs or anti-incontinence procedures.[37]
There was not a single instance of trocar site recurrence in any
patient in the series we reviewed and report on herein.
Survival
A review of 11 studiesof survival rates for endometrialcarcinoma
patients treated by a laparoscopic approach with a mean length
of follow-up of 31.6 months (range, 12 to 76 months) showed
the mean disease-free survival rate to be 95.3% (range, 91.2% to
100%) (Table 16.5.6).[15,18,20,23,25,36,38–42]
When endometrial cancer patients treated by laparoscopy or
laparotomy are compared, similar disease-free survival rates are
observed among both groups of patients. The mean disease-free
survival rate for 468 patients treated by laparoscopy was 96%
(range, 91.2% to 100%) compared with 94.3% (range, 92% to
95.9%) for 331 laparotomy patients (Table 16.5.7). A review
of factors influencing survival showed independent impact by
advanced age, higher stage, higher grade, and degree of myometrial invasion. The type of surgical approach (laparoscopy or
laparotomy) did not influence survival.[36]
Table 16.5.5: Comparison of Recurrences after Treatment
for Endometrial Cancer by Laparoscopy and Laparotomy
Laparotomy Laparoscopy
Patients, Recurrence, Patients, Recurrence,
Study no.%no.%
Kuoppala et al.
(2004) [15]
Eltabbakh
(2002) [20]
Holubetal.
(2002) [23]
Langebrekke
et al. (2002) [25]
Tozzi et al.
(2005) [35]
Obermair et al.
(2004) [36]
Total 477 11.7 654 5.4
40 2.0 50 2.5
86 10.5 100 7.0
44 6.8 177 6.2
22 4.1 26 0
59 8.5 63 12.6
226 14.9 248 4.0
patients treated laparoscopically. In particular, a mean difference
of 21 days was noted for resumption to full activity and of 31.7
days for return to work. Otherstudies alsonoted an earlier return
to full activity in patients treated laparoscopically.[43] However,
no differences were noted for recall of pain control in the two
groups ofpatients (2.4vs. 2.4), although thelaparoscopy patients
required a lower mean dose (32.3 mg) of intravenous morphine
postoperatively compared with 124.1 mg for laparotomy-treated
patients. Nonetheless, no differences were noted for satisfaction
with disease management by laparoscopy or laparotomy (2.5 vs.
2.6).
Cost
Cost analyses have indicated similar or reduced costs for the
laparoscopicapproachcomparedwith the standard open abdominal technique. Of four published studies addressing cost analysis, two reported lower costs for patients in the laparoscopic
group [22,31] and two reported similar costs for the two procedures (Table 16.5.8).[21,30] The mean cost for laparoscopy was
$10,959 compared with $12,379 for laparotomy, for a $1420 difference. The range of costs for laparoscopy was $5198 to $13,809,
compared with $5331 to $17,119 for laparotomy.[21,22,30,31]
In the former two reports [22,31], operating room charges
were higher for the laparoscopy group, but the shorter hospitalization resulted in an overall lower cost. In the latter two studies [21,30], similarly increased operative costs were noted for
laparoscopy patients, but these were offset by shorter hospitalization. In particular, increased fees for surgeons and anesthesiologists and increased operating room charges were noted for
laparoscopy patients, whereas the laparotomy patients incurred
increased hospitalization and pharmacy charges.
Quality-of-Life Measures
An analysis of quality-of-life measures comparing patients treated
by laparoscopy and laparotomy [20]showed a favorable trendfor
Contraindications
A laparoscopic approach is contraindicated in any patient with
a large uterus that cannot be removed intact through the vagina
Laparoscopy for Endometrial Cancer — 471
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Table 16.5.6: Disease-free Survival (DFS) for LaparoscopyTreated Patients with Endometrial Cancer
Mean
Study Patients, no.
Kuoppala et al. (2004) [15] 40 34 100
Tozzi et al. (2005) [18] 63 44 91.2
Eltabbakh (2002) [20] 100 27 93
Holub et al. (2002) [23] 177 33.6 93.7
Langebrekke et al. (2002)
[25]
Obermair et al. (2004) [36] 226 29.4 98.2
Liauw et al. (2003) [38] 30 15.5 100
Lim et al. (2000) [39] 40 29.5 92.5
Magrina et al. (2004) [40] 45 76 94.7
Malur et al. (2001) [41] 37 16.5 97.3
Siow et al. (2003) [42] 16 20–60 100
Total 801 31.6
∗
Excluding Siow et al. (2003).
27 12 100
Follow-up, mo. DFS,%
∗
95.3
Table 16.5.7: Comparison of Disease-free Survival between
Laparoscopy- and Laparotomy-Treated Patients with
Endometrial Cancer
Disease-free Survival
Laparoscopy, no.
Reference
Kuoppala et al. (2004) [15] 40 (100) 40 (95)
Eltabbakh (2002) [20] 100 (90) 86 (92)
Holub et al. (2002) [23] 177 (93.7) 44 (93.2)
Langebrekke et al. (2002) [25] 27 (100) 24 (95.9)
Peng et al. (2004) [29] 24 (100) 41 (97)
Tozzi et al. (2005) [35] 63 (91.2) 59 (93.8)
Malur et al. (2001) [41] 37 (97.3) 37 (93.3)
Total 468 (96) 331 (94.3)
(%)
Laparotomy,
no. (%)
Table 16.5.8: Overall Cost Analysis Comparison between
Laparoscopy and Laparotomy for Endometrial Cancer
Laparoscopy cost,
Study
Eltabbakh (2002) [20] 13,003 11,878
Gemignani et al. (1999)
[22]
Scribner et al. (1999) [30] 5198 5331
Spirtos et al. (1996) [43] 13,809 17,119
US $
11,826 15,189
Laparotomy cost,
US $
and also in medically compromised patients for whom a laparoscopic approach might not be safe. In our experience, medically
compromised patients are almost exclusively obese patients with
respiratory compromise. Although no reports have attested to
the risks of morcellating a uterus containing malignancy, it violates the elemental principle of cancer surgery of extirpating an
intact tumor site whenever possible. Obesity, in the absence of
respiratory deficit, should not be a contraindication in the hands
of an expert anesthesiologist and gynecologic oncologist. Nor
does a history of adhesions contraindicate laparoscopy. If thick,
dense adhesions preventing laparoscopy are noted on entry, the
surgeon would soon realize a laparotomy is necessary. However,
manypatients with ahistoryofprevious pelvic surgeriesmayhave
a paucity of adhesions or those they do have may be easily lysed
so the planned procedure can be carried out. In such instances,
a different placement or additional insertion of trocars may be
necessary.
SPECIAL CLINICAL SITUATIONS
Morbidly Obese Patients
As the body mass index increases and the thickness of the subcutaneous tissue increases, so do the difficulty of the operation
and the risk of postlaparotomy wound infection, respectively.
Laparoscopy is and should continue to be the preferred approach
for morbidly obese patients, even if only to eliminate or reduce
the risk of wound infection, evisceration, or subsequent ventral
hernia formation.
There are no major contraindications to use of the Trendelenburg position for morbidly obese patients. It does, however,
require a more labor-intensive anesthesia because prompt ventilation adjustments are needed throughout the operation and the
anesthesiologist must maintain a watchful eye for hypercarbia.
The feasibility of the laparoscopic approach in obese patients
has been demonstrated. Endometrial cancer can be treated
successfully in the majority of obese and morbidly obese
patients. Of 91 morbidly obese patients treated by laparoscopy
in three studies, 83 (91.2%) had a successful procedure. [21,34,
44] When conversions due to advanced disease or other
anatomic or abnormal surgical findings are excluded, the success rate is 95.7% for conversions due only to intraoperative
complications.[15,20,23,25,29,35,41]
Perioperative differences noted between the two groups are
similar to those observed between lower-weight patients (Table
16.5.2). Compared with the laparotomy group, the laparoscopy
patients hadsimilar or longer operating times, similar or reduced
blood loss, and shorter hospitalization.[21,34,44] Other authors
have noted similar findings among obese patients.[27]
Obese laparotomy patients experienced a wound infection
rate 28 times higher than that of laparoscopy patients (54.2%
vs. 1.9%; Table 16.5.9) [21,34,44], securing an important reason for selection of a laparoscopic approach in such patients. In
one small study, all four of four laparotomy patients had wound
infection whereas none of the four laparoscopy patients experienced wound infection.[44] In another study, wound infections
occurred in 15 of 31 laparotomy patients (48.4%) butin onlyone
of 47 laparoscopy patients (2.1%) converted to laparotomy.[34]
In the presence of a markedly thick and redundant abdominal pannus, the laparoscopic trocar may not be long enough to
472 — Javier F. Magrina, Andrea Mariani, and Paul M. Magtibay
https://t.me/med1917
Table 16.5.9: Comparison of Perioperative Laparoscopy and Laparotomy Data for Obese Patients with Endometrial Cancer
Mean Operating
Study Patients, no.
Laparoscopy
Eltabbakh et al. (2000) [21]
Obermair et al. (2005) [34]† 47 139 279 7.9 4.4 6.3 2.5
Yu et al. (2005) [44] 4 154 325 NA 4 0 0
Total 91 163 307 9.6 3.6 4.4 1.3
Laparotomy
Eltabbakh et al. (2000) [21]
Obermair et al. (2005) [34]
Yu et al. (2005) [44] 4 143 700 NA 11.5 100.0
Total 121 136 441 12.7 8.3 74.2
∗
Body mass index between 28 and 60 (weight [kg]/height [m2]).
†
Mean weight, 121.6 kg.
‡
The only patient with wound infection had a laparotomy conversion.
§
Mean weight, 113.7 kg.
NA, not available.
∗
∗
§
40 195 318 11.3 2.5 2.5 NA
86 138 303 5.3 5.6 — NA
31 127 320 20.0 7.9 48.4
Time, min.
reach or penetrate sufficiently into the abdominal cavity. With
such patients, the torque necessary to manipulate the laparoscopic instruments may also result in arm fatigue or detract from
precision. Removal of the pannus, a medically indicated panniculectomy, not an abdominoplasty, allows direct placement of
the trocars on the anterior abdominal wall fascia and facilitates the
performance of the laparoscopic approach. The postpanniculec-
Mean Blood
Loss, mL
Mean Lymph
Nodes, no.
Mean Hospital
Stay, days
Conversion to
Laparotomy,%
Infection,%
toneal cytologic findings and two withpositivepelvic nodes).[46]
These patients had no intraoperative complications, had a mean
operative blood loss of 50 mL, andhad a mean hospital stayof 1.5
days (range, 0 to 3 days). The mean interval from hysterectomy
to laparoscopy was 47 days (range, 14 to 63 days). One patient
who experienced deep venous thrombosis after being discharged
was readmitted for anticoagulation treatment.
Wound
tomy wound infection rateis lower than that after a conventional
laparotomy incision in similarly obese patients.[45] In a series of
87 noncosmetic panniculectomy patients with endometrial cancer operated on at the Mayo Clinic, the wound infection rate was
2.3%. This finding compares favorably with the wound infection
rate of2.3% observed in 1179 gynecologic inpatients operated on
at the same institution.[45]
In morbidly obese patients,ourapproachistoperform a vaginal hysterectomyand abilateral salpingo-oophorectomy in select
patients with endometrioid, low-grade tumors and then to proceed with staging if indicated by frozen section. This approach
shortens the laparoscopic operating time, if it is indicated on
the basis of prognostic factors by the frozen section, and it also
eliminates the demands of a more challenging laparoscopic hysterectomy or panniculectomy.
Recurrent Endometrial Cancer
Patients with a pelvic recurrence of endometrial carcinoma after
initial surgery or after surgery followed by irradiation are candidates for salvage therapy, in particular those with involvement of
the vaginal cuff. Some patients with clinically apparent isolated
pelvic or vaginal recurrence have concomitant metastatic disease
at additional abdominal sites, which may go undetected even
with advanced imaging techniques. In a series of eight patients
with pelvic recurrence explored by laparotomy, three(37.5%)had
upper abdominal disease. In patients with central pelvic recurrence who are candidates for pelvic exenteration, the procedure
is abandoned at laparotomy about one third of the time.[47]
Reasons for unresectability are direct peritoneal involvement by
tumor,intra-abdominal peritoneal disease,retroperitonealnodal
disease, and involvement of the lateral pelvic wall.[47] In a series
SURGICAL STAGING AFTER UNEXPECTED
ENDOMETRIAL CANCER IN A
HYSTERECTOMY SPECIMEN
of 31 patients with recurrent endometrial carcinoma who were
candidates for exenteration,the procedurewasabandoned in four
(12.9%).[48] Reasons included intraperitoneal metastases, posi-
tive retroperitoneal nodes (pelvic or aortic), and lung metastases.
Laparoscopy is useful for completion of disease treatment and
for surgical staging in patients found to have an unexpected
endometrial cancer after a hysterectomy performed for benign
indications. In a series of 13 such patients, laparoscopic staging
was useful in removing the remaining adnexa and in detecting
extrauterine disease inthreepatients(23%;onewithpositiveperi-
Laparoscopic peritoneal and retroperitoneal exploration before
pelvic irradiation, upper vaginectomy, or exenteration affords
detection of intraperitoneal and retroperitoneal metastatic sites.
These patients obviously requireadifferenttherapeuticapproach,
and their recurrent disease carries amuchworse prognosis. In our
experience with two patients with recurrent endometrial cancer
‡
Laparoscopy for Endometrial Cancer — 473
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after irradiation, pre-exenteration laparoscopy revealed the presence ofan unresectable tumor affixed to the common iliac vessels
and sacral promontory in one patient and peritoneal invasion
by a tumor in the other patient. A laparotomy was avoided in
both patients. In two series that included 21 pre-exenteration
laparoscopic explorations for recurrent cervical cancer, laparotomy was avoided in 12 patients (57.1%) who had contraindications because of metastases.[49,50] The mean operating time
was 112 to 150 minutes.[49,50] Patients were hospitalized for 3
days and were able to initiate chemotherapy on the second postoperative day.[49]
Pre-exenteration laparoscopy is a valuable tool for potential candidates because it eliminates unnecessary laparotomies,
decreases surgical morbidity in already compromised patients,
reduces unused operating room time, and alleviates the emotional burdenon patients in whom it is not performed. The overall exenteration time is reduced because of the previous exploration, because patients are aware of the extent of the operation,
and because operating room efficiency is increased because none
of the planned exenterations is aborted.
CONCLUSION
When perioperative results for endometrial cancer patients
treated by laparoscopy or laparotomy are analyzed, patients
treated by laparoscopy are found to have reduced operative
blood loss and hospitalization, increased operating time, a similar or reduced number of lymph nodes, and a similar or reduced
number of postoperative complications. Tumor recurrence and
disease-free survival rates are similar for both groups of patients,
whereas costs remain reduced for laparoscopy-treated patients
because of their shorter hospitalization.
The type of surgical approach (laparoscopy or laparotomy)
was the only identified significant risk factor predictive of intraand postoperative complications for patients 65 years of age or
older, weighing more than 80 kg, and with a Quetelet index of
more than 30. In this particular group of patients, laparoscopy is
associated with a significantly lower risk of complications. Obese
or morbidly obese patients have similar results and advantages
compared with lower-weight patients, and they are ideal candidates for laparoscopy. Insuchpatients,theriskofwoundinfection
is reduced 39 times when theprocedureis performed laparoscopically.
If either of two cancer treatments provides similar survival
and recurrence rates and is associated with a lower morbidity, it
should be the preferred therapeutic approach. Such is the case
for the primary surgical treatment of patients with endometrial
cancer when considering whether to treat them with laparoscopy
or laparotomy. Unfortunately, it will take a new generation of
gynecologic oncologists trained in advanced laparoscopic techniques before the laparoscopic approach will become universal
for treatment of endometrial cancer.
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41. Malur S, Possover M, Michaels W, Schneider A. Laparoscopicassistedvaginalversusabdominalsurgeryinpatientswithendometrial cancer–aprospectiverandomizedtrial. Gynecol Oncol.
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43. Spirtos N, Schlaerth J, Bross G, Spirtos T, Schlaerth A, Ballon
S. Cost and quality-of-life analyses of surgery for early endometrial cancer: laparotomy versus laparoscopy. Am J Obstet Gynecol.
1996;174:1795–1800.
44. Yu C, Cutner A, Mould T, Olaitan A. Total laparoscopic hysterectomy as a primary surgical treatment for endometrial cancer in
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45. Stanhope C, Winburn K, Silverman M. Indicated noncosmetic
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49. Dargent D, Ansquer Y, Mathevet P. Can laparoscopic para-aortic
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Section 16.6. Laparoscopic Management of Ovarian Cancer
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Ali Mahdavi and Farr Nezhat
The American Cancer Society estimates that more than 22,000
women will be diagnosed with ovarian cancer in 2007.[1] Of
these 22,000 patients, 25% will have stage I disease, for which
5-year survival rates approach 90%. However, numerous studies have shown that a significant percentage of patients with
apparent early-stage (stage I) ovarian cancer actually harbor
microscopic metastatic disease. Consequently, the benefits of surgical staging for epithelial ovarian carcinoma have been well
established.[2] Traditionally, it has been recommended that a
comprehensive surgical staging procedure for epithelial ovarian and fallopian tube cancers include a total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritonealcytologic
washings, biopsies of adhesions and peritoneal surfaces,omentectomy, and retroperitoneal lymph node sampling from the pelvic
and para-aortic regions through a generous vertical midline
laparotomy incision.[2] With the advent of minimally invasive
surgical techniques, surgeons are now able to perform all of the
necessary procedures for comprehensive surgical staging laparoscopically, including laparoscopic pelvic and para-aortic lymphadenectomies and omentectomies, in selected patients. Small
series of laparoscopic staging of early ovarian cancer (EOC) have
been reported, and preliminary data suggest that the minimally
invasive approach in experienced hands is adequate to perform
comprehensive surgical staging.[3]
Querleu and Leblanc [4] in 1994 reported complete laparoscopic surgical staging procedures for ovarian or fallopian tube
cancer. Eight referred patients with ovarian and fallopian tube
cancers underwent complete laparoscopic staging after inadequate initial surgical staging. Since this initial series, others have
confirmed the feasibility of comprehensive laparoscopic surgical
staging of ovarian or fallopian tube cancers.[5]
Recently, the results of a GOG study [6] to determine the
feasibility of laparoscopic completion staging in patients with
incompletely staged gynecologic cancers were reported. Of 95
eligible patients, 73 had incompletely staged ovarian, fallopian
tube, or primary peritoneal cancer. Eleven patients were later
excludedbasedonpathology review,progressionofthedisease,or
incompletedocumentation.Fifty-eight (69%) of these 84 patients
weresuccessfullycompletelystagedwithphotographic documentation. Nine (10%) and 17 (20%) of 84 patients were incompletely staged or required conversion to laparotomy, respectively.
In patients undergoinglaparoscopy, 6% had bowel complications
and 11% were found to have more advanced disease. Hospital stay
was significantly shorterwith laparoscopyalone (3 vs. 6 days, P =
0.04). The investigatorsconcludedthatinterval laparoscopicstaging of gynecologic malignancies can be successfully undertaken
in selected patients, but laparotomy for adhesions or metastatic
disease and risk of visceral injury should be anticipated.
One of the largest and most recent reports is by Tozzi and
colleagues [7], who described 24 cases of ovarian cancer in which
laparoscopic staging was performed. In this series, all surgical
specimens, except for the primary ovarian tumor(s), were free of
disease. One patient (4%) developed a postoperative complication, and no long-term complications were noted. Seven patients
(29%) had tumors of low malignant potential, and six (25%)
had stromal or germ cell tumors. Five (21%) of the 24 patients
received postoperative chemotherapy. With a median follow-up
of 46 months, the disease-free survival rate was 92% and the
overall survival rate was 100%. Although these survival results
are difficult to interpret in a patient cohort in which less than
half the patients (11/24) had invasive carcinomas, the average
of 38 lymph nodes per patient compares favorably with series
of both laparoscopic staging and staging performed via laparotomy. Moreover, this study demonstrates that with proper training and experience, extensive laparoscopic lymphadenectomies
can be performed with minimal morbidity. The major advantages in patients with EOC treated by laparoscopy were the lower
rate of intra- and postoperative complications and the shorter
length of hospitalization. A reported rate of complications ranging between 10% and 30% in patients with EOC stagedor restaged
by laparotomyexceedsthe3%to7% rate reported in patientswho
underwent laparoscopy. A faster recovery may be relevant for the
administration of chemotherapy in patients upstaged as a result
of the restaging procedure. Whetherdelayin starting theadjuvant
chemotherapy has a prognostic impact is yet to be demonstrated,
but because clear data are lacking, the procedure associated with
less morbidity should be followed. Survival outcomes, such as
disease-free and overall survival, were in the range of 90% to
100% for laparoscopy and did not differ in patients managed by
laparotomy. The number of patients was probably too small to
definitivelyrule out an influence of laparoscopyontumorgrowth.
However, the absence oftrocar metastasis andthe favorable prognosis indicatedthatlaparoscopydidnotpromoteor inducetumor
dissemination as postulated in some case reports.[8]
BORDERLINE OVARIAN TUMORS
Borderline ovarian tumors (BOTs) do not invadethe basalmembrane but may spread widely acrossperitonealsurfaces.Theytend
to occur in patients younger than those with invasive epithelial
ovarian cancer,andtheirprognosisisbetterthanthe latter.Fifteen
percent to 40%of serous BOTsare associated withperitoneal disease. Theprognosis for suchpatients with advanced-stagedisease
is perceptibly different from those with stage I disease. The most
important prognostic factor is the type of peritoneal implants
475
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(invasive or noninvasive). Prognosis of patients with noninvasive
implants remains good if the totality of peritoneal implants is
removed. The treatment is exclusively surgical, without adjuvant
treatment. Inselectedcasesofyoungpatientswithadvanced-stage
disease, a conservative surgery could be proposed to maintain
fertility.[9]
The use of the laparoscopic approach to conservatively treat
BOTs appears attractive because such management theoretically
reduces postoperative adhesionsand therefore could increasefertility results. There are few data on the laparoscopic management
of BOTs. Three series were published and one was reported in
abstract.[10–12] These papers demonstrated that laparoscopic
treatment of BOTs is feasible and safe in patients with early-stage
disease (apparent “stage I”disease).Inaddition, pregnancies after
laparoscopic staging have been reported. Seracchioli et al. [11]
reported six pregnancies among 19 patients, Camatte et al. [10]
described 17 pregnancies in 34 patients, and 12 pregnancies were
reported in the seriesof Donnez et al.[12]Therefore,laparoscopic
staging of BOTs is attractive, particularly in young patients desiring pregnancy.
There are very few data on the laparoscopic management of
advanced-stage borderline tumors. Deffieux et al. [13] reported
nine patients who underwent a laparoscopic treatment of stage
II/III serous borderline tumor. Laparoscopic treatment of peritoneal implants included omentectomy (or omental biopsies) in
four patients and/or large peritoneal resection in five patients.
Each implant was less than 5 mm. Four patients recurred; three
of them had a borderline ovarian recurrence after conservative
management. Two patients hadperitoneal disease found during a
second-look surgery (associated with ovarian recurrencein one).
Three spontaneous pregnancies were observed. All patients were
alive without evidence of diseasewith amedian time of follow-up
of 35 months following the laparoscopic treatment. This series
suggests that laparoscopic treatment of patients with BOTs associated with small-size noninvasive implants is feasible, seems to
be safe, and remains an attractive alternative for young patients
wishing to preserve their fertility.
Figure 16.6.1. Metastatic lesions of the right hemidiaphragm and culde-sac are noted in the upper abdomen and deep pelvis upon initial
inspection.
SURGICAL TECHNIQUE
A multipuncture operative laparoscopic approach is used as previously described.[14] A 0
◦
5- or 10-mm transumbilical videolaparoscope is used. Pelvic washings are collected for cytology, and
parietal and visceral peritoneal surfaces of the deep pelvis and
middle and upper abdominal cavities are thoroughly inspected
(Figure 16.6.1). Any suspicious growth is biopsied. In the case of
normal visual exploration,eight to 10 random peritonealbiopsies
are performed in the Douglas pouch, pelvic and abdominal parietal peritoneum,paracolic gutters, hemidiaphragms, and mesentery. Small andlarge bowel can also becarefully inspected laparoscopically. “Running” the small bowel can be accomplished from
the ileocecal valve to the ligament of Treitz using two atraumatic
bowel graspers (Figure 16.6.2). When conservative treatment is
considered, biopsy of the contralateral ovary is performed only
in the case of suspicious growth. In this context, dilatation and
curettage are performed so as not to miss a possible endometrial
spread or a synchronous tumor. Every attempt shouldbe made to
avoid the rupture of a suspicious adnexal mass in the abdomen,
including choosing unilateral adnexectomy over ovarian cystec-
tomy, limited manipulation of the mass, use of nontraumatic
graspers, and preventive coagulation to avoid bleeding, which
may obscure the identification of the cleavage planes. Additional
safety measures are the removal of the specimen exclusively via a
laparoscopic bag and control of the bag integrity once extracted
(Figure 16.6.3). Laparoscopy is intrinsically limited by the size
of the trocar incisions. Even when the incision is enlarged, a
puncture is required to remove large masses. If the puncture can
be located within an Endobag (United States Surgical), and the
Endobag’s integrity is preserved, the procedure is safe according
to previous findings.
To achieve an infracolicomentectomy, the patient is placed in
a straight supine position and the omentum is excised from the
inferior margin of the transverse colon using a harmonic scalpel,
a bipolar forceps and Endoshears (United States Surgical), a linear stapler, endoligature, or sutures. The harmonic scalpel and
endoligature are superior for omentectomy because of minimal
plume formation, ease and speed of use, and lack of protruding
staple edges (Figure 16.6.4). The omentum specimen can also be
removed with an Endobag (Figure 16.6.5).
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